Healthcare Provider Details

I. General information

NPI: 1174964357
Provider Name (Legal Business Name): RICHARD ANTHONY PECKHAM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANTHONY DIRZLER RN

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

IV. Provider business mailing address

817 PRINCE AVE
TIFTON GA
31794-4053
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-4815
  • Fax: 229-890-6777
Mailing address:
  • Phone: 229-376-2859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN162464
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: